The goal of this pre-doctoral training is to develop knowledge about End of Life (EOL) decision-making in vulnerable populations that is both culturally appropriate and patient centered. The Patient Self Determination Act (PSDA) passed by Congress in 1990 required all health care facilities to inquire about a patient's wishes about medical treatments in advance of serious or critical illness (advance directive). Several studies have suggested that this effort to promote patient autonomy may in fact be culturally biased or paternalistic. The role of poverty and other contextual factors that may influence patients' willingness to express their wishes about care at the EOL has not been well described. The specific aims of this research training plan are to: 1) describe contextual factors that influence EOL decision-making in vulnerable populations, 2) identify patient preferences for participating in EOL decision-making and 3) describe interpersonal and environmental strategies that may affect EOL care in vulnerable populations.